"We are the only country in history that ever deliberately changed its ethnic makeup, and history has few examples of 'diversity' creating a stable society." - Richard Lamm, former governor of Colorado

Tuesday, June 12, 2007

Concurrent sex partners and HIV/AIDS in Africa

Has the tide turned away from AIDS orthodoxy? Two books — strikingly different in tone and character — recount the global response to the AIDS pandemic with words of recrimination for the United Nations (UN). Helen Epstein and James Chin each raise searching questions about methods and motives, saving their most pointed barbs for UNAIDS, the body that coordinates the work of ten separate organizations within the UN system on the pandemic and tracks its spread.

[snip]

Having been right on prevalence, Chin has to be taken seriously when he dismisses UNAIDS' doomsday predictions for India and China. Yes, this pandemic is an unparalleled public-health emergency, he says, but the double-digit prevalence rates seen in parts of Africa will never be reached elsewhere. That's because HIV takes hold among members of high-risk groups (men who have sex with men, injecting drug users, female sex workers), but only fans out to general populations where patterns of multiple, concurrent sexual relationships are the norm. Thus in many African countries, HIV travelled from a member of a high-risk group to each of his or her regular sex partners, then to their multiple regular partners, who introduced the virus to other networks until a vast web formed. It was not the number of sex partners — people everywhere average roughly the same number over their lifetimes — but the synchronicity of the encounters. According to Chin, in most of the world outside east and southern Africa, a culture of serial rather than concurrent sex partners has so far, and will continue to, confine HIV epidemics to high-risk groups. He predicts a slow rise in prevalence rates due primarily to life-prolonging treatment and to new infections, which from here on, he says, will be confined largely to people whose regular sex partners are HIV-positive.

If Chin is right — and to the non-scientist, at any rate, his textbook-like narrative is certainly provocative — the UN has wilfully deceived. Why? Because, he contends, the larger the numbers, the greater the carnage and the more the money flows in. Because associating the continent's horrific AIDS ordeal with African sexual practices might seem like racial stereotyping. Because it's easier to conduct prevention programmes among the general public than among the high-risk groups at society's edges. But why not over-reach, spreading prevention messages to entire populations, including those at highest risk? Because, Chin argues, given limited resources, only targeted prevention programmes can protect those most likely to become infected. Yet in place of that simple piece of logic, he sees an AIDS gestalt created in the service of fundraising.

[snip]

There's much in Chin's book that Helen Epstein, author of The Invisible Cure: AIDS in Africa, would find palatable. Like Chin, she holds the bold view that the virus spreads beyond high-risk groups to the general population only through web-like networks of concurrent sex partners.

With elegant prose, a scientific background and a journalist's searching anecdotal eye, Epstein combines personal research and corroborative evidence from others to posit the view that where Africa's AIDS rates are highest, the key difference is not the numbers of sexual partners, but the timing. She then applies her theory to Uganda, the one country in Africa where a culture of concurrent sex partners was well entrenched and yet the prevalence rate of HIV/AIDS has been reduced dramatically since 1990.

Epstein describes how President Yoweri Museveni rallied his country in the 1980s with the mantra 'Zero Grazing' that cautioned Ugandans not to have more than one partner at a time. She acknowledges the application of 'ABC' — abstain, be faithful and use condoms — but asserts that an abrupt end to the practice of concurrent relationships was the decisive factor in reducing prevalence.

[snip]

And then, like Chin, Epstein goes after UNAIDS. Mind you, her criticism is almost Victorian in its gentility, albeit unmistakable in its target. Where Chin uses a hatchet, Epstein wields the scalpel. She argues persuasively that the UN has long known that reduction in the number of sexual partners has been a factor wherever rates have fallen, from Uganda to San Francisco, and yet it refuses to act on it. Is it lack of respect for indigenous cultural awareness and survival instincts? She recounts how in 1993, a statistician now in the top ranks of UNAIDS misrepresented (mistakenly, it seems) findings about Uganda's success, erroneously claiming that researchers had noted an uptake in condom use and delay in sexual initiation, but no significant reduction in concurrent partners. The distortion prevailed. "It was only in 2006 that UNAIDS officials began to stress that the reduction of multiple sexual partnerships should be a key goal for AIDS prevention programmes in southern Africa," she reports. When the organization's executive director Peter Piot was asked about the omission in a list of questions Epstein sent him in 2004, he answered every question but that one.